This
document is an update of McKeel 1996 ('A clinician's guide to research on solution-focused
therapy', in Miller, S.D., Hubble, M.A. and Duncan, B.L. (eds), Handbook of Solution-Focused
Brief Therapy (pp. 251-71). San Francisco: Jossey-Bass.). It is copyright and
all rights are reserved to the author. It may not be quoted without appropriate
citation. For permission to reproduce it in whole or in part please contact the
author at jaymckeel@aol.com

A
selected review ofresearch of solution-focused brief therapy

A.
Jay McKeel

Useful
research addresses the needs and interests of the many consumers of research studies,
including clinicians, clients, educators, students, theorists, third-party payers
of psychological services, and health maintenance organizations (HMOs). Research
of solution-focused brief therapy (SFBT) presented in this review concludes that
the model is effective and that many techniques of the model accomplish their
intended purpose. This article also provides a summary of studies that describe
how clients describe their experience of SFBT.

Unfortunately,
many research consumers will decide that the research of SFBT does not meet their
needs. Few outcome studies of SFBT use experimental, quantitative outcome research
that can provide some readers with convincing results, and few studies compare
SFBT with other therapeutic models. Studies of SFBT techniques can ask more useful
questions and use multiple measures to investigate the effectiveness of the interventions.
More research asking clients about their experience of SFBT and specific techniques
would be welcomed by many clinicians and research consumers.

This
review has four parts. First is a review of outcome studies of SFBT. Next, investigations
of SFBT techniques are presented. The third section describes information from
and about clients about their experience of SFBT. The last section offers ideas
for new research of SFBT. Finally, this article offers suggestions for investigating
SFBT that many research consumers will find more useful.

Outcome
StudiesOutcome
studies address questions such as, "Is this therapeutic approach or model
effective?" "If this model is effective, then when and with whom?"
"Is this model better than other therapeutic approaches?" Existing outcome
studies of SFBT have rarely used comparison groups, random assignment to treatment
conditions, or strong and varied outcome measures. This limits the confidence
that therapists and other research consumers will have in the findings and conclusions
of this body of research.

Is
brief therapy effective?A
large body of clinical research shows that brief therapy is an effective approach
for most clients, including clients with severe and chronic problems. Studies
comparing brief therapies with longer-term therapies show no difference in success
rates between the two approaches (see Koss & Shiang, 1994, for a comprehensive
review of research about brief therapies).

Is
SFBT effective?In
a study conducted at BFTC, Kiser (1988) and Kiser & Nunnally (1990) report
an 80% success rate in a six-month follow up of clients receiving SFBT. [The researchers
reached the 80% success rate by combining clients who reported they met their
goal (65.6%) and those who reported significant improvement (14.7%).] A more recent
study completed at BFTC, in which the researchers conducted seven to nine month
follow-ups of 141 clients who received SFBT, reports a 77% success rate (De Jong
& Berg, 1998). [This success rate was calculated by combining clients who
met their goal (45%) and those who made some progress (32%).] In another study
of SFBT, Lee (1997) reported a 64.9% success rate in a six-month follow-up [54.4%
met their goals and 10.5% partly met their treatment goals]. Macdonald (1994;
1997) found success rates of 70% at a one-year follow-up and 64% after three years.
Together these studies present consistent evidence that SFBT is effective.

Other
research studies have examined the effectiveness of SFBT with specific client
populations. For example, de Shazer & Isebaert (1997) report a 74% success
rate for 250 inpatient clients and a 73.5% success rate for 72 outpatient clients
with alcohol problems. An outcome study by Eakes, Walsh, Markowski, Cain, &
Swanson (1997) found SFBT successful in treating five clients with a diagnosis
of schizophrenia.

Other
research studies have found that SFBT is effective in an Occupation Therapy setting
(Cockburn, Thomas, & Cockburn, 1997), in schools (Lafountain, Garner, &
Eliason, 1996; Littrell, Malia, & Vanderwood, 1995), in Social Work Agencies
(Sudman, 1997), and in prisons (Lindforss & Magnusson, 1997).

Is
SFBT brief?In
a study of 275 cases receiving SFBT, De Jong and Berg (1998) report that the average
number of sessions was 2.9. Clients in the Macdonald (1994) study attended an
average of 3.84 sessions. de Shazer and Isebaert (1997), reporting on an outpatient
SFBT treatment program for problem drinking, report clients attended an average
of 4.6 sessions. Johnson & Shaha's (1996) study reports the average number
of sessions of clients receiving SFBT was 4.77. Lee (1997) reports the average
number of sessions of 59 families who received SFBT was 5.5.

The
number of sessions of SFBT that a client attends and whether that client accomplishes
their treatment goals seem related. In Macdonald's (1994) follow-up study, clients
who reported a good outcome had an average of 5.47 sessions, while those who reported
their situation was the same or worse than before therapy attended an average
of 2.67 sessions. Another study found that clients who received three sessions
or less of SFBT had a success rate of 69.4% while clients attending four or more
sessions had a success rate of 91.1% (Kiser, 1988; Kiser & Nunnally, 1990).

Is
SFBT better than other therapy models?Three
studies comparing SFBT with other treatment models report that SFBT accomplishes
equal or superior outcome results in an Occupational Therapy Setting (Cockburn,
Thomas, & Cockburn, 1997), prisons (Lindforss & Magnusson, 1997) and schools
(Littrell, Malia, & Vanderwood, 1995). These studies use stronger research
designs by comparing SFBT with an existing treatment, randomly assigned clients
to treatment conditions, and using more established outcome measures. No comparative
outcome study has investigated SFBT in a traditional outpatient therapy setting.

The
Lindforss & Magnusson (1997) is a good model for comparative outcome studies.
Sixty prisoners were randomly assigned to receive either SFBT or the existing
treatment (control group) provided to inmates. The outcome measure was re-arrest
(recidivism) during two follow-up periods: 12 months after the inmate was released
and again at 18 months. At 18 months, 40% of the inmates who received SFBT had
not been re-arrested while only 14% of the control group had not been re-arrested,
which was a statistically significant difference. The SFBT group had fewer arrests
in the 18 months following their release from prison (86 vs. 153) and the SFBT
group spent less time in prison for those arrests (86 vs. 136).

Consumers
of the Lindforss & Magnusson (1997) research include prison administrators
and clinicians who work with prisoners. These investigators compared SFBT with
a treatment that these consumers were already using; without this comparison,
these clinicians and administrators would have no convincing evidence that SFBT
produced better results. Also, the investigators selected an outcome measure that
is meaningful to these consumers: recidivism. This type of research design and
outcome measures produces results that will interest research consumers and lead
to improvements in services therapists provide.

SFBT
TechniquesSolution talkde
Shazer (1988; 1994) encourages therapists to use change-talk or solution-talk.
Examples of solution-talk include the therapist asking about pretreatment improvements,
noticing differences between problem and non-problem times, expressing optimism
that the client's situation will improve, and exploring action that the client
can take to accomplish their goals.

Early
in the development of SFBT the Milwaukee team used research to discover that when
therapists use solution-talk, clients usually respond by talking about improvements
in their situation or view of their situation (Gingerich, de Shazer, and Weiner-Davis,
1988). This study revealed the BFTC team rarely used solution-talk early in their
first sessions; because of this research project de Shazer and the team to begin
asking about change earlier in the first session.

Another
study found that the more a client uses solution-talk in his/her first session,
the more likely the client is to continue their therapy. Also, the more clients
talk about solutions or goals in their first session, the more likely they are
to complete treatment rather than drop out (Shields, Sprenkle, and Constantine,
1991).

Pretreatment
improvementDuring
a first session, solution-focused therapists usually ask clients what improvement
in their problem have occurred since their call to request therapy (de Shazer,
1985; 1988). If the client reports any improvement, the therapist and client explore
what the client(s) did to accomplish that improvement. Exploring pretreatment
improvements may also help clients identify steps to take to continue helping
their situation. Identifying pretreatment changes may lead clients to feel encouragement
because they realize their situation can improve.

Research
shows that pretreatment improvement is common. Allgood, Parham, Salts, & Smith
(1995) found that 30% of 200 clients reported pretreatment improvement in the
situation that led them to seek therapy. A study reviewing data from 2400 clients
found that 15% made significant improvement before attending their first session
(Howard, Kopta, Krause, & Orlinsky, 1986).

How
does pretreatment change affect the process and outcome of therapy? One study
found that clients who report pretreatment change are four times more likely to
complete therapy than clients who report no pretreatment change (Johnson, Nelson,
& Allgood, 1998). Additional studies about pretreatment improvements could
ask: What differences exist between clients who do and do not report pretreatment
change? Are clients who report pretreatment change more optimistic about accomplishing
their goals? Do clients believe doing more of what led to pretreatment improvement
will help them accomplish their treatment goals?

Presuppositional
questionsPresuppositional
questions are leading questions that communicate a belief or expectation. O'Hanlon
and Weiner-Davis (1988) recommend to therapists: "...instead of, 'Did you
ever do anything that worked?' ask, 'What have you done in the past that worked?'...
The latter [question] suggests that inevitably there have been successful past
solutions." (p. 80). Solution-focused therapists use presuppositional questions
as interventions to help clients recall and discuss information about their strengths,
abilities, and successes.

Studies
show that clients are more likely to report pretreatment improvements when asked
presuppositional questions. Weiner-Davis, de Shazer, and Gingerich (1987) asked
clients in their first session, "Many times people notice in between the
time they make the appointment for therapy and the first session that things already
seem different. What have you noticed about your situation?" (p. 360). This
question presupposes pretreatment improvement has occurred. Twenty of the thirty
clients asked the question reported pretreatment improvements and gave specific
examples regarding the problems that led them to seek therapy.

Replications
of this study also found that more than 60% of clients who were asked a similar
question by their therapist in their first session identified something about
their problem that was better (Lawson, 1994; McKeel & Weiner-Davis, 1995).
Johnson, Nelson, & Allgood (1998) asked clients a presuppositional question
about pretreatment improvement in a written questionnaire completed before the
beginning therapy and 53% of these clients reported pretreatment change.

Future
research of presuppositional questions may explore issues other than pretreatment
change. For instance, does a presuppositional question at the beginning of the
second or subsequent session (e.g., "So, what has been better since I saw
you last?") increase clients' reports of between-session improvement? Other
research could explore if and how presuppositional questions lead clients to develop
new views about themselves and their situation.

Miracle
questionIn
the first session of SFBT, therapists usually ask clients the miracle question.
The therapist asks,

Suppose
that one night, while you were asleep, there was a miracle and this problem was
solved. How would you know? What would be different? . . What will you notice
different the next morning that will tell you that there has been a miracle? What
will your spouse notice?" (de Shazer, 1991, p. 113).

In
a qualitative study of the miracle question, twelve volunteers from a parental
support group completed a one hour interview in which they were asked the miracle
question. All twelve provided answers to the question. Some answers were realistic
while others were idealized. These participants gave three categories of answers
to the miracle question: concrete (e.g., a better home to live in), relational
(e.g., closer relationships with loved ones), and affective/emotional (e.g., happier).
After answering the miracle question, most participants felt more hopeful about
their situation (Dine, 1995).

In
a study of clients receiving SFBT, clients explained that the miracle question
helped them focus on their goals for treatment and helped them focus on doing
something different to accomplish their goals. These clients also felt more hopeful
about their situation after answering the question (Shilts, Rambo, & Hernandez,
1997).

In
a study of SFBT couples' therapy, researchers interviewed clients at the end of
treatment to find out if they remembered their therapist asking the miracle question.
Most clients did, but few could remember how they answered. Clients were more
likely to recall their spouse's answer than their own (Odel, Butler, & Dilman,
1997).

Nau
(1997) observed experienced SFBT therapists conducting first sessions and discovered
two factors important in effectively asking the miracle question. First, the therapist
must clearly join with the client before asking the question. Second, the technique
is more effective if the therapist explores exceptions with the client before
asking the miracle question.

Formula
First Session Taskde
Shazer and Molnar (1984) explain that the Formula First Session Task (FFST) is
the homework assignment that SFBT therapists typically give clients to complete
between their first and second session. The FFST asks clients: "Between now
and the next time we meet, I would like you to observe, so that you can describe
to me next time, what happens in your (family, life, marriage, relationship) that
you want to continue to have happen" (de Shazer, 1985, p. 137). One goal
of using the FFST is to promote optimism by suggesting to a client that positive
things will happen. Clients responding to the FFST in the second session often
report new, positive steps that they have taken in their lives (de Shazer, 1985).

One
study found that in their second session, 89 percent of the clients assigned the
FFST reported that something positive and worthwhile had occurred since their
first session and 57% reported that their situation was better (de Shazer, 1985).

Adams,
Piercy, and Jurich (1991) compared a SFBT first session, which included assigning
the FFST, with a problem-focused first session using a problem-focused first session
task. At the beginning of their second session, the therapist followed up on the
task. Clients assigned the FFST were more likely to have completed the task, more
clear about their treatment goals, and more likely to report improvement in their
presenting problem. However, clients assigned the FFST were not more optimistic
about accomplishing their goals in therapy.Jordan and Quinn (1994) also compared
the FFST with a problem-focused first session task. In the second session, clients
assigned the FFST were more likely to report improvements in their problem, more
likely to expect their therapy would be successful, and more likely to rate their
first session as productive and positive.

Therapists'
views of SFBT techniquesSkidmore
(1993) surveyed graduates from three SFBT training programs to assess their views
of scaling questions, exception questions, miracle questions, and pretreatment
change questions. Miracle questions and pretreatment change questions are described
above. With scaling questions, SFBT therapists ask a client to rank his/her problem,
perception, motivation, prediction, or any clinically relevant issue on a scale
of one to ten (de Shazer, 1994). Therapists ask clients exception questions to
identify when the problem was less severe or did not exist and what the client
did to accomplish this (O'Hanlon & Weiner-Davis, 1989).

Of
these four SFBT questions, therapists rated the miracle question as the most therapeutic.
Scaling questions were the most frequently used and therapists rated these questions
as the best way to evaluate a client's progress. Therapists described exception
questions as typically leading a client to report exceptions and improvements
in his/her problems and to describe what he/she did to achieve the change. Therapists
rated questions about pretreatment changes as the least effective of the questions
and the most difficult to use successfully use (Skidmore, 1993).

When
evaluating SFBT, clients explain that their relationship with their therapist
is more important than any specific technique their therapist uses. "[T]hey
appreciate those therapists who are respectful and take the time to 'listen' to
the families' story. Families consistently report that therapy appears most beneficial
when the therapist appears caring and concerned" (Shilts, Rambo, & Hernandez,
1997, p. 129).

On
the other hand, clients are critical of SFBT when they do not develop a close
relationship with their therapist or do not feel heard and understood. One client
noted, "We just never connected . . . he never understood our situation"
and another client explained, "We were in the middle of a huge crisis and
I don't think he picked up on it" (Odel, Butler, & Dielman, 1997). In
their study of SFBT couples' therapy, Odell, Butler, and Dielman (1997) found
that "when one member of the couple felt a lack of connection [with their
therapist], therapy was over."

DropoutsBeyebach
& Carranza (1997) compared clients who dropped out of SFBT with those who
completed therapy. The researchers described clients who dropped out as more conflictive
and domineering in their session than clients who completed therapy. The researchers
concluded that when therapists are supportive and respectful in SFBT, clients
are more likely to complete treatment.

GenderJordan
and Quinn (1997) compared males' and females' reactions to SFBT after two sessions.
No significant difference was found between men and women regarding four variables:
outcome optimism, self-efficacy, outcome expectancy, and session positivity. In
their six-month follow-up outcome study of 141 clients who received SFBT, De Jong
and Berg (1998) found no significant difference between men and women regarding
treatment success.

The
Next Step in Researching SFBTWell
designed and relevant clinical studies can benefit therapists, clients, theorists,
educators and trainers, students and trainees, third-party payers, HMOs, and other
consumers of research. Researchers who use different research methods, samples,
data, and analysis will attract the interest of different audiences. For instance,
an HMO may be interested in quantitative outcome studies of SFBT while some therapists
will be more interested in qualitative studies that describe the effective use
of SFBT questions. Future studies must continue to explore many research questions
and use multiple research methods that meet the interest of varied research consumers.

This
section suggests strategies researchers can use to address the needs of some SFBT
research consumers. Third party payers of psychological services, trainers and
educators, and many clinicians want results that well-designed quantitative outcome
studies of SFBT provide. Clinicians who want practical and easy-to-gather information
about improving services to their clients can use simple qualitative studies to
meet their needs.

Experimental
quantitative outcome researchExperimental
quantitative outcome research using established measures is noticeably absent
from SFBT research. Both clinicians and researchers have long valued this type
of research as "an essential activity and as the type of research that has
the largest impact on practice" (Schwartz & Breunlin, 1983, p. 25). In
this age of HMOs and therapist accountability, such research would enhance the
credibility of SFBT. When conducting quantitative outcome research of SFBT, investigators
should address the following issues.

Define
SFBT. Existing outcome studies of SFBT typically fail to provide basic information
about the model practiced by the therapists in the study. de Shazer and Berg (1997)
urge researchers to "demonstrate that the model of therapy being tested is
indeed the model used by the therapists [in the research study]. Otherwise any
and all findings are suspect." (p. 123).

However,
a rigid protocol of SFBT in research studies conflicts with the "do what
works; if it does not work, do something different" philosophy of the model.
To remedy this, studies of SFBT can encourage therapists to do what they consider
is best for their clients. After treatment is finished, the investigator can review
the case to determine if it meets the criteria for inclusion in a study of SFBT.
While this research strategy presents some methodological problems, it has three
advantages: better representing how SFBT is actually practiced, allowing the investigator
to discover if and when SFBT practitioners deviate from or abandon the model,
and it best meet clients needs.

Design
comparative studies. Future quantitative outcome research needs to randomly
assign clients to two or more treatment conditions. Almost all existing research
of SFBT has no comparison group, a design that Kerlinger (1986) deems scientifically
worthless.

Past
useful quantitative research has used several types of comparison groups. A comparative
outcome strategy compares the model under examination (the experimental group)
with an established model (the control group) to determine if the new model compares
favorably or produces better results than the control model.

A
dismantling outcome strategy compares two groups to learn what components of the
model are necessary or sufficient for treatment success. For example, research
could test the importance of SFBT homework assignments in treatment outcome; one
group of clients would always be assigned SFBT homework while the other would
be assigned either no homework or non-SFBT homework. A constructive outcome strategy
could be used to test new techniques or ideas by conducting traditional SFBT with
one group while the other group receives SFBT plus the new idea. Finally, outcome
studies can compare two groups based on therapist characteristics; for instance,
comparing a team approach to therapy conducted by an individual therapist or comparing
experienced and novice therapists (Kazdin, 1994).

Researchers
debate the merits and ethics of a no-treatment control group; that is, comparing
a group of clients receiving treatment with clients who receive nothing. Some
argue that this type comparison group is necessary to prove that a particular
model produces therapeutic improvement by determining if people who call to request
therapy may be as likely to resolve their problems without any clinical help (e.g.,
Kazdin, 1994).

Other
researchers believe using a no-treatment control group is unnecessary and unethical
(e.g., Todd & Stanton, 1983). These researchers argue that no-treatment groups
are no longer necessary because a sufficient body of research shows that people
are significantly more likely to improve their situation if they receive therapy.
More importantly, denying services may be unethical and even dangerous for many
clients asking for therapy, especially when violence, suicidal thoughts, eating
disorders, or substance abuse are problems.

When
researchers use multiple measures, they speak to the various consumers of research
studies. Some therapists will be satisfied with relying only on clients' perceptions
of their treatment while others will place more confidence in the results of a
study that also includes success ratings from the therapist or other observer
(this is especially true regarding the treatment of substance abuse or violence).
Third-party providers may have more confidence in a model that demonstrates its
effectiveness with traditional research measures and instruments.

The
success of treatment can be measured in multiple ways. Client self reports can
be global (my marriage is better), affective (I am happier), behavioral (we spend
more time together), and cognitive (I do not worry about divorce now). Observational
data can be collected from therapists and/or others (e.g., a team behind a mirror
or an interviewer who meets with the client). Standardized tests are another important
tools available for researchers wanting to demonstrate treatment success.

Franklin,
Corcoran, Nowicki, and Streeter (1997) offer one method of collecting outcome
data that may interest SFBT practitioners. Clients develop scales (0 = client
fails to make any movement toward goals; 10 = client is completely satisfied).
Johnson (personal communication) has also developed a method for tracking client
progress based on a 1-10 rating scale which uses scaling to track clients' progress.

Variance
between therapists. Research literature consistently demonstrates that some
therapists are more effective than others. Future studies of SFBT should collect
data about therapist characteristics, practice, and therapeutic philosophy to
identify variances between therapists and to detect which variables relate to
better success rates of more effective therapists. Understanding what more effective
therapists do may contribute more useful information to clinicians than any other
type of research results.

A
simple qualitative studyConsistent with the philosophy of SFBT, simple
research can also be good research. Here is a low cost, easy-to-do research study
currently being conducted at Bowie Youth & Family Services. Clinicians and
clients both find this questionnaire useful. We also expect it will also provide
more general information about how clients use therapy to accomplish their goals.

Our
agency asks clients to complete this questionnaire before their second and subsequent
sessions. Clients report this questionnaire motivates them to take more action
to change and appreciate that their therapist cares about their progress and what
the client considers important to do in their sessions. It helps therapists better
understand what our clients want from us. The questionnaire includes the following
questions:

1.
What was most useful about your last session?2. What changes has your family
made since your last session?3. What can you and your therapist do today that
will help you accomplish your goals?4. How can therapy better meet your needs?

At
the beginning of each session, clients give their questionnaire to their therapist
who begins the sessions by responding to clients' answers.

After
collecting enough responses, Bowie Youth & Family Services will review the
answers to identify patterns or categories of responses. The categories the investigator
develops would be guided by the answers clients gave to these questions, but examples
of categories that might occur include: developing a plan of action, feeling support
from the therapist, using therapy to make important decisions, and better understanding
my spouse. The result can describe what clients find useful and what they want
from therapy.

Clinical
research should offer clinicians information that helps them better serve to their
clients. Studies such as the Bowie project accomplish that goal in the short term
(by providing relevant, on-the-spot information to the therapist about what the
client has and will find useful) and in the long-term by reporting findings of
this study to other therapists.

ConclusionsOutcome
studies of SFBT show that the model is effective and prompts positive outcomes
for most clients. SFBT is successful with most clients and produces positive outcomes
for a variety of clinical problems and in a variety of settings. However, a serious
omission from this body of research is well-designed quantitative experimental
outcome research. Such studies would promote stronger confidence in the effectiveness
of SFBT.

Studies
of SFBT techniques have found that: (a) when therapists use solution-talk, their
clients are more likely to talk about change. The more clients use solution-talk,
the more likely they are to complete their therapy. (b) Pretreatment improvement
is common. (c) Presuppositional questions usually accomplish their goal of helping
clients notice strengths, improvements, and past successes. (d) The miracle question
can help clients focus on their treatment goals and feel more optimistic about
their situation. (e) Clients usually complete the FFST and report improvements
when assigned that homework. (f) SFBT therapists frequently use scaling questions.

(g)
SFBT therapists report that exception questions typically prompt clients to talk
about exceptions and improvements regarding their problems. (h) Therapist find
questions about pretreatment change to be the most difficult to use effectively.

This
body of research also tells us that focusing solely on techniques misses one key
to successful SFBT: the client-therapist relationship. The study by Odell, Butler,
and Dielman (1997) highlights this: although therapists were asking the miracle
question, assigning the FFST, and using other SFBT techniques, if a client did
not feel their therapist heard and understood them, they left therapy. Studies
of the perceptions of clients highlight the importance of therapists' relationship
with their clients and that SFBT is successful when it is both solution-oriented
and client-oriented.

Todd,
T. C., & Stanton, M. D. (1983). Research on marital and family therapy: Answers,
issues, and recommendations for the future. In B. B. Wolman & G. Strickler
(Eds.), Handbood of family and marital therapy (pp. 91-115). New York: Plenum.

Warner,
R. E. (1996). Counsellor bias against shorter term counselling? A comparison of
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